Provider Demographics
NPI:1497119556
Name:JOHNSON, KELLY R (LMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 163333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32816-3333
Mailing Address - Country:US
Mailing Address - Phone:407-823-2924
Mailing Address - Fax:407-823-4352
Practice Address - Street 1:4098 LIBRA DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-3333
Practice Address - Country:US
Practice Address - Phone:407-823-2924
Practice Address - Fax:407-823-4352
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 12142101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor